SENSORY EVALUATION LABORATORY

FOOD AND NUTRITION RESEARCH INSTITUTE

Document Code:
Screening Questionnaire
Revision
Page: 1 of 1
Effectivity Date: Jan. 2015


We are recruiting panelists for sensory evaluation of the products being developed at the Food and
Nutrition Research Institute. We would like to match your product preferences, usage and sensory skills to these
products. Please accomplish this questionnaire and indicate your answers by putting a check () in appropriate
boxes. All information will be maintained confidential.

Personal Information
Last Name

First Name

Middle Name

Birthdate (mm/dd/yy)

Gender
Male Female
Status
Single Married
Section/ Division

Position Regular Contractual

Address/Contact Information
Street No./Name

Town/Municipality

City/Province

Telephone/ Mobile No

Office/Business No.

E-mail address


1. Are you interested and willing to become one of our sensory panelists? Yes No
2. Are you pregnant? Yes No
3. Please indicate which, if any, of the following foods disagree with you (allergy, discomfort, religious
belief, customs and traditions, others)
Cheese (specify) ____________ Poultry _____________________
Chocolate _________________ Seafood ____________________
Eggs _____________________ Beans, Nuts _________________
Fruits (specify) ______________ Spices (specify) ______________
Meats (specify)______________ Vegetables (specify) __________

Milk ______________________ Others (specify) _____________

4. Please indicate if you are on a special diet

Diabetic,

Gluten Free

High Protein

Vegetarian

High Fiber

Kosher

Halal

Artificial sweeteners only

Low Sodium

Low Fat

Dairy free

High Calorie

Low Calorie

No special diet

Others (specify) ________
5. Do you smoke? Yes, how much do you smoke in a day? ___________
Never
Used to be a smoker but have quitted smoking
When did you quit smoking? _________________
6. Do you have dental problems? Yes ___________________ No
7. Do you go on field work? Yes No
If yes, how often? ____________________________
how long? _____________________________
Signature: ____________________
Date: ____________________